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PubMed1988

[Total hip arthroplasty in the presence of sepsis].

Sixty-seven cases of total arthroplasty of the hip in the presence of sepsis performed between 1974 and 1986 were reviewed. These prostheses were inserted in 57 cases to replace septic prostheses. Forty-six were infected total hip prostheses and 11 were infected head and neck replacement femoral prostheses. In 10 cases arthroplasty was performed for subacute septic arthritis, usually secondary to trauma. In seven cases, a simple revision of the prosthesis by excision and lavage of infected tissues was performed. In 51 cases, a total hip replacement arthroplasty was performed in one stage. When one of the components was not loose it was preserved; in 17 cases the femoral cement was retained and in six the acetabular cup was retained. In eight cases, the prosthesis was removed, excision of the tissues was made and a total hip arthroplasty inserted after a minimum interval of six months. As regards infection, success was achieved in 69 per cent of cases rising to 85 per cent after secondary removal of the prosthesis. In relation to function, a good or fair result was achieved in 72 per cent of cases. The results were favourable in 81 per cent of cases with complete exchange of prostheses and in 75 per cent with preservation of the femoral cement. Preservation of the acetabular cup was only successful in 40 per cent of cases. Accessory factors in the prognosis were the addition of a bone graft, which became incorporated in 29 cases out of 30 and the nature of the organism which was of no significance, except that staphylococcus epidermidis and Koch's bacillus proved to be more easy to treat.

Acetabulum↗
PubMed1988

Old sepsis prior to total knee arthroplasty.

A retrospective study of 65 cemented total knee arthroplasties in previously infected knees was performed. Two subgroups were identified: in Group I there was prior infection of both the bone and joint (20 patients) and in Group II there was only joint involvement (45 patients). Following primary total knee arthroplasty, deep infection occurred in three of 20 (15%) in Group I and in two of 45 (4%) in Group II, or five of 65 (7.7%) overall. Subsequent revision arthroplasty was required in 18. Of these 18 knees, three (17%) developed deep infection. Old sepsis, especially with associated osteomyelitis, results in a high rate of infection following total knee arthroplasty.

Adult↗
PubMed1988

Autogeneic cancellous bone grafting following transtrochanteric hip arthroplasty. An attempt to facilitate union of the greater trochanter.

A technique involving the use of autogeneic cancellous bone to facilitate union of the greater trochanter following hip arthroplasty via a transtrochanteric approach is presented. This technique has not been previously reported for a large series of patients. Two hundred thirty-five patients were treated with 286 hip arthroplasty procedures via a transtrochanteric approach. All trochanters were advanced 1-2 cm distally and reattached using a three-wire technique. In 111 procedures, cancellous bone taken from the excised femoral head or neck was placed at the inferior aspect of the osteotomy site. In the remaining 175 procedures, no bone grafting was performed. Retrospectively, the incidences of trochanteric nonunion at two-year follow-up evaluation for the nongrafted versus the grafted groups were as follows: 5.7% (10 of 175) versus 2.7% (3 of 111) overall incidence, 4.3% (6 of 139) versus 1.2% (1 of 85) in patients with no previous hip surgery, 8.7% (2 of 23) versus 0% (0 of 10) in patients with previous hip surgery (excluding previous hip arthroplasty), and 15.4% (2 of 13) versus 12.5% (2 of 16) in patients following revision arthroplasty. There was no significant difference in incidence of nonunion between the grafted versus nongrafted groups in any of these categories (chi-square analysis). However, a lower incidence of trochanteric nonunion was found for the patients with autografts in each category, which may indicate a beneficial effect of cancellous bone grafting following trochanteric osteotomy.

Aged↗
PubMed1988

Total hip arthroplasty in the ankylosed hip. A ten-year follow-up.

Eighty total hip arthroplasties in seventy-four patients who had had either a spontaneous or a surgical ankylosis (arthrodesis) of the hip were evaluated at nine to fifteen years (average, 10.4 years) after the total hip replacement. There was only one failure in the twenty hips of the fifteen patients who had had a spontaneous ankylosis. In contrast, twenty (33 per cent) of the sixty hips of the sixty patients who had had a surgical ankylosis had complications that were associated with the arthroplasty. Of these twenty hips, mechanical loosening developed in eleven; infection, in eight; and recurring dislocation, in one. Failure of the total hip arthroplasty was more common (p less than 0.05) in the patients who had had a previous surgical attempt at arthrodesis and in the patients who were fifty years old or less at the time of the arthroplasty. The risk of failure was not related to the length of time that the hip had been ankylosed.

Activities of Daily Living↗
PubMed1987

Treatment of acute femoral neck fractures with total hip arthroplasty.

Between 1973 and 1983, 27 patients with acute femoral neck fractures were treated at the UCLA Medical Center with total hip arthroplasty. These cases were selected on the basis of age, high activity level, and degenerative changes in the acetabular cartilage. The average age was 72 years. There were 19 women and eight men. The average follow-up period was 3.8 years with a range of one to ten years. Methods used included analysis of clinical data, roentgenograms, final pain ratings, walking ratings, and activity levels using the UCLA rating system. Pain relief and overall functional results were better than that of most series of acute femoral neck fractures treated with hemiarthroplasty and similar to that of total hip arthroplasty series. The complication rate was slightly less than both authors' elective total hip series, and considerably less than most hemiarthroplasty series. Complications included a superficial wound infection, a urinary tract infection, and a perforated colon diverticulum. Four patients died within one year from causes unrelated to the hip arthroplasty. There were no deep infections, dislocations, or reoperations. Total hip arthroplasty in selective cases of acute femoral neck fractures can give more consistent pain relief and better functional results than hemiarthroplasty, without an increase in complications.

Acute Disease↗
PubMed1987

Hinged knee replacement in revision arthroplasty.

Fifty-two Stanmore hinged knee replacements were used as revision arthroplasties for failed arthroplasties. The patients were followed for a mean of 44.7 months. On clinical examination, 23% had good, 48% fair, and 29% poor results. Worst results were achieved when revising bulkier or more constrained primary knee joints. Two patients exhibited radiologic evidence of loosening, but at the latest follow-up examination no patients had clinical evidence of loosening. There was an infection rate of 4%. In view of the poor results and the advent of a new generation of knee arthroplasty devices, hinged knee implants may have only a limited place in revision arthroplasty.

Aged↗
PubMed1987

Hip arthroplasty in patients with systemic lupus erythematosus.

Forty-three prosthetic hip replacements (twenty-nine conventional total hip replacements and fourteen bipolar endoprosthetic replacements) were implanted between January 1971 and June 1982 in thirty-one patients who had systemic lupus erythematosus. All but four patients had stage-III or IV osteonecrosis of the femoral head. The median age at operation was forty-three years, and the median length of follow-up was fifty-seven months. Ratings were good or excellent for all but three total hip arthroplasties at a mean of sixty-six months of follow-up. Complications included delayed wound-healing (in approximately 15 per cent) and superficial wound infection (in approximately 10 per cent). The occurrence of these complications could not be correlated with the use of corticosteroids at the time of the operation. Twenty-five per cent of the patients, who were a mean of forty-three years old at operation, died less than five years postoperatively from complications related to systemic lupus erythematosus. Conclusions regarding the systemic effects of hip arthroplasty in patients with systemic lupus erythematosus could not be drawn on the basis of this study. Total hip arthroplasty uniformly provided a good or excellent result in patients of all ages who had systemic lupus erythematosus at a mean length of follow-up of sixty-six months. An increased incidence of local wound complications, which were unrelated to the use of corticosteroids, should be expected in patients with systemic lupus erythematosus who undergo prosthetic arthroplasty of the hip.

Adult↗
PubMed1986

Low-friction arthroplasty of the hip. A 10-12-year follow-up study.

The data from a series of patients operated upon by Charnley and reviewed after ten to 12 years shows that low-frictional torque arthroplasty remains a sound concept of design. If done with precision, it is still the best operation for patients with discomfort and disability from coxarthrosis. The development of a sound interface is controlled not only by the initial strength of the interlock achieved by the surgeon, but also by the loads applied to it by the patients. The total hip arthroplasty may be a miracle of modern medicine, but it can never be superior to normal articulation; this should encourage the surgeon to steer the patient away from unreasonable expectations. In this review, 217 arthroplasties were performed in 184 patients; 58 died, leaving 153 arthroplasties in 126 patients. Eighty-eight percent were more than satisfactory; 6% required revision. This was due to aseptic loosening in only two percent.

Adult↗
PubMed1987

Freeze-dried proximal femur allografts in revision total hip arthroplasty. A preliminary report.

Failure of cemented total hip arthroplasty can emerge from several causes and may be associated with severe bone loss in the proximal femur with a marked diminution in functional capacity of the limb. This is a preliminary report of 14 patients with revision operations for failed total hip arthroplasty. Freeze-dried allograft bone ws implanted for restoration of extensive bone loss in the proximal for restoration of extensive bone loss in the proximal femur. All 14 patients were operated on to salvage failed cemented total hip arthroplasties. Allografts were employed only for large proximal femoral deficiencies. In these patients the alternatives were either an unstable excision arthroplasty or a femoral deficient prosthesis. After revision, all patients had complete bony union and ambulated with the assistance of a cane with greatly increased function and pain relief. There were no infection. Functionally, the patients have shown marked improvement. At this time there is no radiologic evidence of resorption of the graft. The use of bone allografts in this procedure has been encouraging to date; however, the follow-up period has been only 16-30 months. the success or failure of this procedure will be determined in time.

Adult↗
PubMed1985

Hip replacement arthroplasty in rheumatoid arthritis.

Numerous factors conspire to make hip replacement arthroplasty for rheumatoid arthritis different from the same operation in osteo-arthritis. Patients are frequently younger, arousing fears that the patient will outlive the prosthesis. However this factor is more than counterbalanced by the constraints imposed by the disease in other joints: polyarticular involvement usually protects the hip arthroplasty from weight-bearing stress thus prolonging its life. Protrusio acetabuli, uncommon in osteo-arthritis is the commonest presentation in rheumatoid arthritis because of the concentric cartilage degradation which erodes the acetabulum medially and proximally. In arthroplasty for protrusio, a plea is made for grafting of the floor of the acetabulum with solid bone derived usually from the femoral head. This offers a stronger and more physiological support for the acetabular component than synthetic devices. The hip is often only one of the many joints requiring arthroplasty to maintain locomotor function in severe cases of rheumatoid and the results of multiple operations are usually very gratifying. However, any form of surgery may be contra-indicated in a patient enfeebled by prolonged immobilisation from involvement of multiple joints. Late infection of cemented prosthesis is commoner in rheumatoid than in osteo-arthritis: such patients need antibiotic cover during transient bacteraemia from any cause such as dental extraction, trivial infections etc.

Acetabulum↗
PubMed1986

Conventional versus resurfacing total hip arthroplasty. A long-term prospective study of concomitant bilateral implantation of prostheses.

Fifty patients requiring bilateral total hip arthroplasty underwent a concomitant conventional hip arthroplasty on one side and an articular resurfacing procedure on the other, done by the senior one of us (M. A. R.). The average age of the patients was sixty-two years (range, twenty-one to eighty-seven years), and forty-seven of them were followed with serial radiographs and clinical evaluation for one year or more. The length of follow-up was five years for thirty-four patients with both prostheses intact. The average pain score for all hips at three years postoperatively was 5.5 points. Although the majority of patients at each follow-up interval did not prefer one procedure to the other, the conventional arthroplasty was significantly superior for those who had a preference, and radiographic evaluation revealed a statistically significant increased incidence of acetabular lucency at the bone-cement interface of the resurfacing arthroplasty at one, two, three, five, and seven years postoperatively (p less than 0.002). Two of the conventional prostheses were revised during this time-period (one because of infection and one, a broken stem) whereas thirteen (26 per cent) of the resurfacing prostheses were revised (eight hips had femoral loosening, five with concomitant acetabular loosening; three had acetabular loosening; and one had a femoral neck fracture) at an average of fifty-two months postoperatively (p less than 0.001).

Acetabulum↗
PubMed1986

Deep sepsis following total knee arthroplasty. Ten-year experience at the University of California at Los Angeles Medical Center.

Between September 1971 and May 1982, at the University of California at Los Angeles Medical Center, 821 total knee arthroplasties were performed in 604 patients, all of whom received perioperative antibiotics. Deep sepsis, proved by a positive culture of a specimen obtained by postoperative arthrocentesis, developed fourteen times in thirteen knees of twelve patients, an incidence of 1.71 per cent. In one of these patients, who had systemic lupus erythematosus and bilateral knee replacement, the right knee became infected with two distinct organisms on two different occasions (separated by ten months). The first infection was probably hematogenous while the second, developing after a dental procedure, definitely was. Over-all, five infections were hematogenous with an identified source and one other was suspected of having a hematogenous origin. The time from operation to the diagnosis of sepsis averaged 8.3 months over-all, but five of the fourteen infections were recognized less than two months after arthroplasty. For the six infections that were assumed to be hematogenous, the time from operation to the diagnosis of sepsis averaged 16.4 months. The major presenting symptom was pain in thirteen of the fourteen infections. The initial treatments of the fourteen infections consisted of intravenous antibiotics in all of them, primary removal of the prosthesis and so-called exchange arthroplasty after five days in one, removal of the prosthesis and fusion in one, arthrotomy and débridement in six, arthroscopic irrigation in three, and antibiotics alone in three (of which one was treated with an exchange arthroplasty after three weeks). At last follow-up, only four of the thirteen prostheses had been salvaged.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗
PubMed1985

Infected total knee arthroplasties.

Thirty infected total knee arthroplasties were investigated in 29 patients over an average interval of 42 months. Eleven infections began in the immediate perioperative period. Six developed from postoperative wound-healing problems. The remainder were late infections. Staphylococcus was found in 16 infections, gram-negative agents in five, mixed organisms in five, and other gram-positives in four. Sixteen knees were arthrodesed, six knees were treated by retention of the components, and two above-knee amputations and one resection arthroplasty were performed. Five patients had two-stage revisions to new components. Evidence of persistent infection was present in three arthrodeses, two retained arthroplasties, and one knee that was revised. Perioperative infections were associated with staphylococcal organisms and responded less favorably to conservative treatment. The failure of primary wound healing demands immediate measures to obtain skin coverage. Retention of the arthroplasty components is possible only in selected patients.

Adult↗
PubMed1979

An uncemented total hip replacement: experimental study and review of 300 madreporique arthroplasties.

Mafreporique arthroplasty is not intended as a bustitute for acrylic cement stabilized arthroplasty but is available as an effective alternative. An experimental and clinical investigation including radiological analysis of 300 madreporique arthroplasties has convinced us of the reality and reliability of biological anchoring by endosteal osteogenesis. The madreporique method does not result in any local or general complications usually associated with the cement technique. Full weight-bearing is permitted at the same postoperative time as the cemented prosthesis. The results at early and interim follow-up periods compare favorably with cemented hip arthroplasties. Living bone that undergoes remodelling provides for long-term anchor of the prosthesis and eliminates the chemical intermediary which leads, more or less, with time to loosening of the implant in a significant number of cases.

Aged↗
PubMed1983

Total knee arthroplasty in juvenile rheumatoid arthritis.

From 1971 to 1981, total knee arthroplasty was performed on forty-eight knees in twenty-eight patients with juvenile rheumatoid arthritis at the Robert Breck Brigham (now Brigham and Women's) Hospital. Seventeen of these patients, with twenty-nine knee-replacement arthroplasties, were followed for from two to eleven years (average, five years) and are the basis for this study. The patients' ages at operation ranged from thirteen to thirty-nine years (average, twenty-three years). Six patients had undergone total hip arthroplasty prior to admission for total knee replacement, and five patients had a total hip replacement performed while they were hospitalized for the knee arthroplasty. Thirteen patients (twenty-one knees) had significant preoperative pain but only three (five knees) had severe discomfort. Four patients were unable to walk, three were household walkers, and ten were limited community walkers. Preoperative deformities of the knees ranged from 20 degrees of varus angulation to 35 degrees of valgus angulation. The average preoperative flexion deformity was 23 degrees and the arc of motion averaged 45 degrees. At follow-up, twenty of the twenty-one knees that had been significantly painful preoperatively were completely relieved of discomfort. The average arc of motion increased by 34 degrees, while in all but one knee the angular deformity had been corrected to zero to 10 degrees of valgus angulation. All but one patient became a limited or full community walker. Complications included one late deep infection and one posterior tibial subluxation. Four knees required subsequent resurfacing of the patella for treatment of pain. We now routinely resurface the patella in all patients with juvenile rheumatoid arthritis who have a total knee replacement. To date no prosthesis has required revision for loosening. Radiolucency of one millimeter or less about the prosthesis was noted at follow-up in eight (30 per cent) of the knees. As custom-made components were required in twelve of the twenty-nine knees, it is obvious that preoperative planning is crucial in the treatment of these patients. Our recent experience has shown that the use of preoperative and postoperative serial casts aids greatly in the correction of severe flexion deformity of the knee. Postoperative manipulation was required for twenty-one of the twenty-nine knees. Skeletal immaturity was not an absolute contraindication to surgery. We think that our results, which showed a marked improvement in both knee function and in quality of life, make the short and long-term risks of knee-implant surgery well worth taking in this patient population.

Adolescent↗
PubMedDate not supplied

Total hip and total knee arthroplasty in juvenile rheumatoid arthritis.

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.

Adolescent↗
PubMed1982

Revision total hip arthroplasty.

In this review, 110 hips in 107 patients underwent revision total hip arthroplasty at The Hospital for Special Surgery and the Robert B. Brigham Hospital. The minimum follow-up period was two years (average, 3.4 years). Failures of the original total hip arthroplasties were due to loosening of the femoral component (44 hips), loosening of both components (23 hips), loosening of the acetabular component (17 hips), fracture of the femoral component (14 hips), recurrent dislocation due to prosthetic malposition (7 hips), acetabular protrusion (3 hips), and fracture of the femoral shaft (2 hips). Sixty-six hips were categorized as good or excellent, and 25 hips were rated as fair. Nineteen poor results were due to: (a) deep infection (2 hips); (b) mechanical failure (15 hips); and (c) recurrent dislocation (2 hips). Complications included infection (3.6%), trochanteric problems (13%), mechanical failure (14%), and progressive radiolucent zones (26%). The quality of the result of a revision total hip arthroplasty is potentially as good as that of the original arthroplasty. However, the higher incidence of infection and mechanical failure reduces the frequency of such good results in the long-term. The extremely high incidence of progressive radiolucent zones at the bone-cement interface makes predictions for even longer term results guarded.

Adult↗
PubMed1982

Symposium on Surface Replacement Arthroplasty of the Hip. Biomechanics: mutifactorial design choices--an essential compromise?

The main flaws to be overcome in realizing the potential success of the double-cup arthroplasty procedure are failures due to femoral cup loosening, acetabular cup loosening, and femoral-neck fractures. The clinical uncertainties include the selection of a suitable patient with adequate bone stock and the technical difficulties associated with (I) reaming the acetabulum adequately, (2) reaming down onto the neck without violating it, and (3) anchoring the components securely by interdigitation of acrylic cement. The higher frictional torques of the double-cup arthroplasty designs are not a clinical loosening issue--the resulting acetabular cement-bone shear stresses are very low. Computer models of both the femoral and acetabular components predict significant stress shielding of the cancellous bone under metal femoral shells. At the rim of the femoral cup, the stresses are increased by a factor of 3 owing to the stress concentration effect and can rise to a factor of 10 if cystic or osteoporotic changes are present. This finding if confirmed in the three-dimensional models may explain some of the femoral neck fractures. The thin polyethylene acetabular cups may also cause a stress concentration effect on the underlying cement and bone. This may explain the higher incidence of radiographic loosening around the acetabulum in double-cup arthroplasty designs compared with total hip replacements. Metal-backed sockets may reduce cancellous bone stresses and appear advantageous. There is no clinical evidence of unusual wear or wear-related problems. However, new material formulations are now either in use or being planned for the double-cup arthroplasty designs. As yet, there have been no published data on hip simulator wear for the efficacy of any of the current or proposed changes. Biologic fixation appears to be the theme for the 1980s. However, the combination of technology, design instrumentation, and patient selection will be critical in achieving success with this technically difficult procedure.

Acetabulum↗